在血栓切除术前行替奈普酶治疗的大血管闭塞性卒中后的功能结局、再通及出血率

Functional Outcome, Recanalization, and Hemorrhage Rates After Large Vessel Occlusion Stroke Treated With Tenecteplase Before Thrombectomy.

作者信息

Gerschenfeld Gaspard, Smadja Didier, Turc Guillaume, Olindo Stephane, Laborne François-Xavier, Yger Marion, Caroff Jildaz, Gonçalves Bruno, Seners Pierre, Cantier Marie, l'Hermitte Yann, Aghasaryan Manvel, Alecu Cosmin, Marnat Gaultier, Ben Hassen Wagih, Kalsoum Erwah, Clarençon Frédéric, Piotin Michel, Spelle Laurent, Denier Christian, Sibon Igor, Alamowitch Sonia, Chausson Nicolas

机构信息

From the Service des Urgences cérébro-vasculaires (G.G., M.Y., M.C., S.A.), Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, APHP; Faculté de Médecine (G.G.), Sorbonne Université, Paris; Service de Neurologie, Unité Neuro-vasculaire (D.S., Y.H., M.A., C.A., N.C.), and Unité de Recherche Clinique (F.-X.L.), Hôpital Sud Francilien, Corbeil-Essonnes; Services de Neurologie (G.T., B.G., P.S.) and Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU Neurovasc; Service de Neurologie, Unité Neuro-vasculaire (S.O., I.S.), and Service de Neuroradiologie Diagnostique et Interventionnelle (G.M.), CHU de Bordeaux; Service de Neuroradiologie Interventionnelle (NEURI) (J.C., L.S.) and Service de Neurologie (C.D.), Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre; Service de Neuroradiologie (E.K.), Hôpital Henri-Mondor, AP-HP, Créteil; Service de Neuroradiologie (F.C.), Hôpital Pitié-Salpêtrière, AP-HP; Service de Neuroradiologie Interventionnelle (M.P.), Hôpital Fondation Rothschild, Paris; and CRSA (S.A.), Sorbonne Université, INSERM, UMRS 938, Hôpital Saint-Antoine, Paris, France.

出版信息

Neurology. 2021 Nov 30;97(22):e2173-e2184. doi: 10.1212/WNL.0000000000012915. Epub 2021 Oct 11.

DOI:10.1212/WNL.0000000000012915

PMID:34635558

Abstract

BACKGROUND AND OBJECTIVES

To investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes (LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC).

METHODS

We retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent brain angiography. The main outcome was 3-month functional independence (modified Rankin Scale score ≤2). Recanalization (revised Treatment in Cerebral Ischemia score 2b-3) was evaluated before (pre-MT) and after MT (final).

RESULTS

We included 588 patients (median age 75 years [interquartile range (IQR) 61-84]; 315 women [54%]; median NIH Stroke Scale score 16 [IQR 10-20]), of whom 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95% confidence interval [CI] 43.0-51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95% CI 17.2-23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 [20.6%]; secondary transfer, n = 106/520 [20.4%]; > 0.99) despite a shorter median IVT to puncture time in directly admitted patients (38 [IQR 23-55] vs 86 [IQR 70-110] minutes; < 0.001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4-86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95% CI 1.4-4.1).

DISCUSSIONS

Tenecteplase before MT is safe, effective, and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that tenecteplase within 270 minutes of LVO-AIS increases the probability of functional independence.

摘要

背景与目的

在常规治疗中，研究替奈普酶静脉溶栓（IVT）在大血管闭塞急性缺血性卒中（LVO - AIS）患者机械取栓（MT）前的疗效与安全性，这些患者要么在IVT后被二次转运，要么直接入住综合卒中中心（CSC）。

方法

我们回顾性分析了在LVO - AIS发生270分钟内接受0.25mg/kg替奈普酶治疗并接受脑血管造影的患者的临床和手术数据。主要结局是3个月时的功能独立性（改良Rankin量表评分≤2）。在MT前（MT前）和MT后（最终）评估再通情况（修订的脑缺血治疗评分2b - 3）。

结果

我们纳入了588例患者（中位年龄75岁[四分位间距（IQR）61 - 84]；315例女性[54%]；中位美国国立卫生研究院卒中量表评分16[IQR 10 - 20]），其中520例（88%）在IVT后被二次转运。47%（n = 269/570；95%置信区间[CI]43.0 - 51.4）的患者实现了功能独立性。120例患者（20.4%；95%CI 17.2 - 23.9）在MT前实现了再通，不同治疗模式（直接入院，n = 14/68[20.6%]；二次转运，n = 106/520[20.4%]；>0.99）的再通率相似，尽管直接入院患者从IVT到穿刺的中位时间更短（38[IQR 23 - 55]分钟对86[IQR 70 - 110]分钟；<0.001）。492例患者（83.7%；95%CI 80.4 - 86.6）实现了最终再通。2.5%的患者（n = 14/567；95%CI 1.4 - 4.1）发生了症状性脑出血。